PUBLIC HEALTHPUBLIC HEALTHDEVELOPING HEALTHY COMMUNITIESPART ONEHEALTH NEEDS ASSESSMENT PROFILEPART TWO

HEALTH PROMOTION PROPOSAL

Theresa Lowry-Lehnen

Specialist Nurse Practitioner

Surrey University 2005

PUBLIC HEALTH

PART ONE: HEALTH NEEDS ASSESSMENT PROFILECONTENTS

Page

1. Introduction

1. Context and Theoretical Framework

4. Identification and Boundary of the Community

5. Practice Population Statistics

5.Wards and Deprivation Scores

6.Ethnicity

6. The Communitys Locality

7. The Communitys Social Structure

7.Lone Parent Households

8. Teenage Pregnancy Rates

8.Elderly Patients Living Alone

9.Children Health Visitors Case Files 2004

11.Key Health Determinants

13.The Communitys Social Activity and Sentiment

14.What Is Being Done?

15. Sutton and Merton PCT (Targets and Aims 2003-2006)

16. The Communitys Health

16.Chronic Illness Patients

17. Chronic Illness Patients and Smoking

18. Key facts Smoking - DoH 2004

18.Governments Targets Smoking DoH 2004

19.Summary of Identified Community Health Needs

Main Health Need Identified ( Requiring Intervention)

(Smoking Among The High Risk - Chronic Disease Group Patients)

20. Conclusion

22. References

PUBLIC HEALTH

Theresa Lowry-Lehnen

General Practice Nurse

PART ONE: HEALTH NEEDS ASSESSMENT PROFILE

INTRODUCTION

Since the first Public Health Act in 1875 there has been a continuing development towards our current understanding of public health, which is influenced by legislation and policy, theory and practice-based research. This paper focuses on current public health policies and how they can be translated into practice. Part One considers the wider determinants of health and the concept of health needs and analyses and evaluates collated data with regard to a community selected from my practice area within the Sutton and Merton Primary Care Trust. Part Two introduces a plan devised to address an identified health need, i.e. smoking among high-risk groups, and critically appraises an appropriate intervention and evaluation strategy, based on the health promotion model by Tannahill (1985). The proposed action plan also incorporates the stages of change model developed by Prochaska and DiClemente (1984 cited by Naidoo & Wills 2000).

Context and Theoretical Framework

Public health is not a new concept, but since the public health movement of the 19th century the concept has changed significantly. Evolving from a somewhat paternalistic movement, public health now stresses the participatory aspect of health promotion, with special emphasis on the empowerment of patients.

The World Health Organisation has been pointed out as a leading international influence on health care policy and practice, with its development of worldwide health initiatives aimed at addressing inequalities (Tinson: 1995). In Britain, the Black Report, published in 1982, confirmed the extent of inequalities in health and health care (Naidoo & Wills 2000). According to Ewles and Simnett (2003), this report highlighted inappropriate health care and a requirement to focus more on the health needs of different groups.

The current view is expressed in the definition of public health given by the Acheson Report (1988) as the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.

The new public health aims to use regulations, fiscal measures, policies and voluntary codes of practice to provide the population with the opportunities to make the healthier choice the easier choice (Naidoo & Wills 2000). According to the World Health Organisation (1998), the new public health is characterised by a comprehensive understanding of the ways in which lifestyle and living conditions determine health status and aims to protect health by supporting lifestyles and creating supportive environments for health.

Making healthy choices easier is the subtitle of the current Labour governments white paper Choosing Health, which identifies an approach which respects the freedom of individual choice and which addresses the fact that too many people or groups have been left behind or ignored in the past (DoH 2004a). Furthermore, the current government stresses that health promotion, with a focus on prevention and tackling inequalities, is one of the key roles of primary care nurses (DoH 2002) and the health service as a whole (DoH 2000, DoH 2004b).

A Health Assessment Profile can help to fulfil such a role in a meaningful way. It has been acknowledged as the most suitable assessment tool for community-based care, marking a shift from the traditional assessment of health needs by nurses on a one-to-one basis to a more collective view which considers the wider and more complex health needs of the community (Tinson 1995).

Such a profile has been defined as the systematic collection of data to identify the health needs of a defined population, and the analysis of that data to assess and prioritise strategies in health promotion (Twinn, Dauncey, Carnell 1990).

In determining health needs, the profiler must be aware of the various ways in which they can be defined: normative needs, felt needs, expressed needs, and comparative needs (Bradshaw 1972 cited by Tinson 1995; Blackie 1998).

A health needs assessment must also take into account wider determinants of health, such as deprivation and poverty, cultural and social influences, education, housing, transport, and environmental factors (Naidoo & Wills 2000, Ewles & Simnett 2003).

Both the various needs and the wider determinants will be addressed in detail in the course of the Health Needs Assessment Profile, which is based on the framework suggested by Tinson (1995).

Tinson (1995) asserts that the first and most essential task in compiling a profile is to identify the community under examination and define its boundaries. It is also important to consider the various dimensions within a community, i.e. its locality (where it is), its social structure (who lives there), its social activity (what happens there) and its sentiment (what is it like to live there) (Orr 1992 cited by Tinson 1995). Finally, the dynamic nature of a chosen community should be taken into account: Tinson (1995) suggests an approach using systems theory as a framework, in which the community as a system can be divided into subsystems, i.e. key health determinants such as employment, education, housing, crime, health care and transport. For this profile, data was collected from a variety of sources, including a GP practice profile I compiled at the surgery where I am based, the Sutton and Merton PCT, local and national government statistics, the latest Northern Wards Participatory Needs Assessment and the national census.

Identification and Boundary of the Community

The community chosen for this profile is the St Helier (Merton) and St Helier North and South (Sutton) practice population of Faccini House Surgery, Middleton Road, Morden, where I am based as a practice nurse. The surgery is situated on the borders of Merton and Sutton and is part of the Sutton and Merton PCT, with 53% of patients living in the borough of Sutton and 47% in Merton ( Faccini House Surgery -GP Practice Profile 2005).

TABLE 1: PRACTICE POPULATION

Faccini House Surgery, Morden

Patients

5630

Male

2834 (50.3 %)

Female

2796 (49.7 %)

Age ranges

0 - 12

991

13 - 18

554

19 - 30

883

31 - 50

1656

51 - 65

614

65+

922

Source: Faccini House Surgery GP Practice Profile (2005)

The practice is situated on the St. Helier estate, which is one of the top ten most socially deprived areas in the South Thames region (Office of National Statistics 2002). Both Sutton and Merton are relatively affluent boroughs but the northern wards of St. Helier South and North (Sutton) and St. Helier (Merton) have high deprivation scores and lower health status (Sutton and Merton PCT 2002). Almost 90 per cent of the practice population live in those three wards.

TABLE 2: WARDS AND DEPRIVATION SCORES

WARDS

PRACTICE POPULATION

DEPRIVATION SCORE (ONS 2002)

St. Helier

47%

25.9

St. Helier North

22%

37.9

St. Helier South

20%

36.6

Rosehill

7%

14.4

Sutton Common

4%

11.2

Sources: ONS (2002), Faccini House Surgery GP Practice Profile (2005)

While Faccini House Surgery does not yet have a complete record of patient ethnicity, Table 4 shows data on ward, local and national data level, with white ethnicity in St. Helier being significantly higher than the London average.

TABLE 4: ETHNICITY

Ethnicity

St. Helier (Merton)

Merton

London

England

White

83.8 %

75 %

71.2 %

92.2 %

Asian

7.7 %

11.1 %

12.1 %

4.6 %

Black

3.8 %

7.8 %

10.9 %

2.1 %

Chinese (other)

2.1 %

3.0 %

2.75 %

0.9 %

Mixed

2.5 %

3.1 %

3.2 %

1.3 %

Ethnicity

St. Helier (Sutton)

Sutton

London

England

White

90.6 %

89.2 %

71.2 %

92.2 %

Asian

3.0 %

4.7 %

12.1 %

4.6 %

Black

3.0 %

2.6 %

10.9 %

2.1 %

Chinese (other)

1.1 %

1.4 %

2.75 %

0.9 %

Mixed

2.2 %

2.1 %

3.2 %

1.3 %

Source: Office of National Statistics 2002

The Communitys Locality

Faccini House Surgery is situated over two kilometres from Morden town centre, three kilometres from Sutton centre and one and a half kilometres from Rosehill. The vast St Helier estate was built in the late 1930s. The houses are small redbrick council style terraced houses, each row backing on to another row of similar type houses. The centralisation of facilities and services has resulted in a lack of local services to meet the population needs. To access most services in the locality travel by bus or car is required. The closest supermarkets are in Rosehill and Morden, and without transport they are difficult for the elderly or those with small children to access (Windshield Survey 2005). There are four primary schools and one high school in the immediate area, with lower educational achievements compared to other schools in more affluent areas of Merton and Sutton (Ofsted 2004). There is a significant lack of green areas and playground facilities for children and the nearest social centres and cafs are in Rosehill and Morden centre (Windshield Survey 2005).

The Communitys Social Structure

The Census 2001 shows that the geographical area of the Faccini House practice population has a high proportion of lone parent households (Table 5). Teenage pregnancy rates are also much higher than average (Table 6).

TABLE 5: LONE PARENT HOUSEHOLDS

St. Helier (Merton)

Merton

London

7.6 %

6.0 %

7.6 %

St. Helier (Sutton)

Sutton

London

11.8 %

6.1 %

7.6 %

Source: Office of National Statistics 2002

TABLE 6: TEENAGE PREGNANCY RATES 2002 (Ages 15-17)

St. Helier (Merton)

Merton

England

54.1 per 1000

40.5 per 1000

46.2 per 1000

Source: Merton Teenage Pregnancy Unit, Office of National Statistics 2002

St. Helier (Sutton)

Sutton

England

63.4 per 1000

35 per 1000

46.2 per 1000

Source: Sutton Teenage Pregnancy Unit, Office of National Statistics 2002

The number of elderly patients aged over 65 registered at Faccini House surgery is 922. The practice population number of elderly patients living alone is 175. 19% of the elderly practice population therefore lives in lone households, a higher proportion than both local and national averages (GP Practice Profile 2005).

TABLE 7: ELDERLY PATIENTS LIVING ALONE

St. Helier (Sutton)

17.4 %

Sutton

13.8 %

St. Helier (Merton)

19.1 %

Merton

12.8 %

England/Wales

14.4 %

Source: Office of National Statistics 2002

Table 8 gives an overview of needs in relation to children and families, as identified by the practice Health Visitors case files (2004).

TABLE 8 : CHILDREN HEALTH VISITOR CASE FILES 2004

There are 78 families with children under the age of 5 registered at Faccini House Surgery, who belong to the Sure Start programme.

There are 22 families with children under 5 years who are considered a low level of vulnerability (Level 1).

There are six families at Level 2, whose needs are complex enough to require more than one agency.

There are two families at Level 3, whose needs are complex and require a co-ordinated multi-agency assessment, service plan and review process.

There are three families at Levels 4 and 5, who have the highest level of vulnerability. Specialist assessment has confirmed the need for specific, sustained and intensive support.

The number of practice population births recorded for 2004 is 95.

The number of practice population low birth weight babies for 2004 is 11. This means 11.6 % of the practice population births for 2004 were low birth weight. Low birth weight is associated with low socio-economic status, smoking, maternal nutrition pre pregnancy, and energy intake during pregnancy (Sutton and Merton PCT 2003b).

Health Visitor Case Files 2004, Faccini House Surgery

From the above data and the key health determinants listed in Table 9 a picture emerges of the geographical area in which the majority of the Faccini House practice population lives. It is an area with high deprivation scores, a high proportion of elderly people, and a much higher than average teenage pregnancy rate. While unemployment rates are the same or only slightly higher than the national average, they are higher than the local average in Merton and Sutton. There is a high percentage of people without qualifications, indicating a level of education lower than both the local and national levels. There is also a higher than local and national average of lone parent households. Rented council accommodation, as opposed to owner occupied housing, is considerably higher than both the local and national average, with a high percentage of accommodation without central heating. There is also a relatively high number of people without private transport.

TABLE 9: KEY HEALTH DETERMINANTS

Limiting long term illness

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

18.7 %

13.8 %

18.2 %

14.8 %

18.2 %

Unemployment

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

3.4 %

3.3 %

3.8 %

2.6 %

3.4 %

Providing unpaid care

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

8.8 %

8.0 %

8.5 %

9.0 %

10.0 %

No Qualifications

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

33.8 %

19.9 %

37.8 %

23.3 %

29.1 %

One person households

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

33.2 %

32.1 %

30.6 %

33.1 %

30.0 %

Households with dependent children

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

31.0 %

28.6 %

37.8 %

30.0 %

29.9 %

Lone parent households with dependent children

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

7.6 %

6.0 %

11.8 %

6.1 %

6.5 %

Owner occupied housing

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

59.7 %

68.8 %

51.8 %

74.3 %

68.9 %

Rented council accommodation

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

26.4 %

9.2 %

42.0 %

10.9 %

13.2 %

Without central heating

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

22.8 %

10.2 %

13.1 %

7.1 %

8.5 %

No car or van

St. Helier (Merton)

Merton

St. Helier (Sutton)

Sutton

Eng/Wales

35.8%

30.1%

35.1%

23.3%

26.8%

Source: Office of National Statistics 2002

The Communitys Social Activity and Sentiment

To find out what the residents themselves think of the St. Helier area (Table 10), data was obtained from the most recent Northern Wards Participatory Needs Assessment (Merton, Sutton and Wandsworth Health Authority 1998).

TABLE 10: RESIDENTS VIEW NORTHERN WARDS PARTICIPATORY NEEDS ASSESSMENT 1998

The St. Helier residents expressed concern about the lack of facilities in the area for young people. This included poor provision of nurseries and after school clubs, with cost being a major issue, especially for single mothers.

With regard to older people, the need for day care, more nursing homes and social services was highlighted. Housing issues were raised, especially the poor provision for older people living alone, and the slow repairs to council houses.

With regard to health issues, the residents were concerned about long GP waiting times, and talk about the closure of St. Helier Hospital. Other concerns about St. Helier Hospital included long waiting lists and the early discharge of patients. Residents felt more resources were required for respite care, mental health, out of hours services, health visitors and social workers visiting the housebound.

With regards to leisure, lack of facilities for young people was a major concern, and was blamed by many residents for an increase in drugs and crime in the area. For adults, facilities were also considered poor, with the need to travel out of the area by limited public transport or expensive taxis.

Environmental issues raised were traffic pollution, graffiti, and the vandalism and destruction of public phones and bus shelters. Regarding safety and crime, residents, both young and old, said they felt unsafe on the streets at night. Much of the crime in the area is thought to be related to alcohol, under age drinking and drugs.

However, long standing and older residents also felt the area had a strong sense of community, helped by having a happy and stable network of family and friends. There was some hostility towards new residents who were regarded as having a reputation of being rough. As a consequence there was some conflict between generations, and differences were also seen to be aggravated by unemployment levels experienced in the area.

( Merton, Sutton and Wandsworth Health Authority 1998)

What is being done?

Since the 1998 Northern Wards Participatory Needs Assessment, there have been some improvements in the area (Table 11).

TABLE 11

A new leisure centre has been built on Middleton Road and was opened to the public in 2002.

Connexions, the governments support advice and personal development service for 13 to 19 year olds, has opened a local centre.

Traffic calming measures and some road and public transport improvements have been put in place.

For the elderly and needy, cook and eat clubs and exercise and falls prevention classes have been introduced in the local area .

(Sutton and Merton PCT 2003b)

The overriding aims of the Sutton and Merton PCT formed in 2002, are to improve local health services, the health of the local population and to address health inequalities (Sutton and Merton PCT 2003a). Table 12 shows the 2003 - 2006 Sutton and Merton PCT targets and aims.

TABLE 12 : SUTTON AND MERTON PCT, 2003-2006

TARGETS AND AIMS (Primary Care)

To shift services nearer to peoples homes, particularly for the management of chronic illness, but also to coordinate with other local agencies both statutory and voluntary to enable the management of health needs to become more local and less hospital focused.

To improve the coordination of services for older people so that they receive the best care in or as close as possible to their homes.

To develop primary care particularly in the more deprived areas where investment has been low.

To address health inequalities

To improve mental health services.

That services for children are directed by the needs of the child.

Develop the ability of communities to improve their own health.

The PCT envisages the provision of diagnosing and treating people where possible in the community .

The PCT plans to work across the interface between hospital and primary care to achieve more support for older people and more outpatient and chronic illness services in primary care.

To ensure access for patients to see a primary care professional within 24 hours and a GP within 48 hours.

The PCT recognises that smoking is a major contributor to ill health, and responsible for the socio-economic gradient in ill health. The target for Sutton and Merton is that 5,441 smokers successfully stop smoking by March 2006.

The Sutton and Merton PCT is aware of and addressing the socio-economic issues which influence the health of many local people, such as, smoking, nutrition, alcohol and drugs, sexual health and teenage pregnancy.

Smoking is a key target and being addressed through smoking cessation services, however the PCT recognises that more needs to be done and more robust efforts are required to ensure services reach those most vulnerable and particularly at risk.

Sutton and Merton PCT 2003a

Sutton and Merton PCT 2003b

Sutton and Merton PCT 2003c

The Communitys Health

There are 220 patients registered at Faccini House Surgery who are currently diagnosed with or who have been treated for cancer. This is equal to 3.9% of the practice population (GP Practice Profile 2005).

Computer records for certain categories of illnesses such as mental health are presently being updated at Faccini House, and I was unable to obtain accurate statistics. Present records identify 15 patients as suffering with severe mental health problems and 82 patients with other mental health problems such as depression. The Practice Manager and GPs believe that the actual figures are much higher (GP Practice Profile 2005).

St. Helier North and South wards have the highest level of chronic illness in Sutton, the former 16% and the latter 14%. The St. Helier ward at 17% has the highest level of chronic disease in Merton (Sutton and Merton PCT 2003a). Table 13 shows the number of patients registered at Faccini House Surgery with asthma, diabetes and coronary heart disease.

TABLE 13: CHRONIC ILLNESS PATIENTS

ASTHMA

DIABETES

CORONARY HEART DISEASE

AGE

NUMBER

AGE

NUMBER

TOTAL

183

0 12

82

0 12

13

13 24

90

13 24

25

25 44

125

25 50

74

45 64

63

50+

104

65 74

25

TOTAL

189

75+

14

TOTAL

399

Source: Faccini House Surgery GP Practice Profile (2005)

The practice population also comprises a high number of smokers. Of the 4,085 patients aged over 18, a total of 1307, or 32%, are registered as smokers (GP Practice Profile 2005). This is a higher proportion than the national average of 26%, but close to the national proportion of those in routine or manual employment who smoke (31%) (DoH 2004a). Of 554 young people aged between 13 and 18 registered at the surgery, 55 smoke (GP Practice Profile 2005), that is 10%, slightly higher than the national average (9%) of 11 to 15 year-olds who smoke (DoH 2004a).

A comparison between smokers and those with chronic illnesses shows that a high proportion of chronic disease patients are smokers. Of the 399 asthmatic patients, 194 or 61% are registered as smokers. Of the 189 diabetic patients, 62 or 35.2% are smokers, and of the 183 coronary heart disease patients, 115 or 63% are smokers (GP Practice Profile 2005).

TABLE 14: CHRONIC ILLNESS AND SMOKING

DISEASE

TOTAL

SMOKERS

PERCENTAGE

Asthma

399

194

61.0 %

Diabetes

189

62

35.2 %

CHD

183

115

63.0 %

Source: Faccini House Surgery GP Practice Profile (2005)

TABLE 15 : KEY FACTS SMOKING (DoH 2004a)

Smoking is the greatest cause of preventable illness and early death in the UK

Smoking is the single biggest cause of health inequalities and is associated with poverty and social deprivation

Over 120,000 people die from smoking in the UK each year.

10,000,000 adults are smokers in England.

26% of adults smoke ( 25% of women, 27%of men)

9% of 11 15 year olds are smokers

Smoking causes a wide range of illnesses, including cancer, respiratory diseases and heart disease

Smoking costs the NHS between 1.4 and 1.7 billion pounds per year in England

70 % of smokers say they would like to stop.

TABLE 16 : GOVERNMENT TARGETS ON SMOKING (DoH 2004a)

To reduce adult smoking rates from 26% in 2002 to 21% or less by 2010

To reduce the prevalence of smoking among routine and manual groups from 31% in 2002 to 26% or less by 2010

Smoking cessation to be embedded in all NHS social care pathways by 2006

The NHS to become a smoke free zone by 2006. Nurses to be targeted to quit smoking as part of a joint DoH and RCN campaign from 2005

Boost smoking cessation campaigns. Provide information, support, NRT and access to NHS support and stop smoking services

Restrict tobacco advertising

In 2005 2006, the Healthcare Commission will examine what PCTs are doing to reduce smoking in the local populations. Progress will be monitored against national standards and indicators

SUMMARY OF IDENTIFIED MAIN HEALTH NEEDS

Table 17 summarises the main health needs identified within the defined practice population and requiring intervention. However, the high incidence of smoking within our practice population, and especially among the high risk chronic disease patients, has been identified as a most serious health need requiring urgent intervention.

TABLE 17: SUMMARY OF IDENTIFIED MAIN HEALTH NEEDS

A high incidence of pensioners living alone = 19%(17.4% for St Helier Sutton, and 19.1% for St Helier Merton, compared to the national average of 14.4%. The large number of lone pensioner households, reflects the need for rehabilitation and home help services

Lone parent households and teenage pregnancy rates, higher than both the local and national averages. (St Helier Merton 51.4 per 1000, St Helier Sutton 63.4 per 1000, compared to 46.2 per 1000across England, 40.5 in Merton and 35 in Sutton. Lone parent households are associated with poverty and social deprivation (Blackburn 1991). This theory is also supported by Whitehead (1988), who also suggests that poverty and ill health are interrelated.

A high incidence of vulnerable children and low birth weight babies. Low birth weight is associated with low socio-economic status (highest in births registered by single mothers), smoking, maternal nutrition pre pregnancy and energy intake during pregnancy ( Sutton and Merton PCT 2003b).

A high number of practice population patients who smoke compared to the national average (32% vs 26%). Smoking is the single biggest cause of health inequalities and is associated with poverty and social deprivation (DoH 2004a).

St Helier North and South has the highest level of chronic illness in Sutton, the former 16% and the latter 14%. The St Helier ward at 17% has the highest level of chronic disease in Merton

(Sutton and Merton PCT 2003a)

A high incidence of chronic disease patients (Asthma, Diabetes and Coronary Heart Disease) registered at Faccini House Surgery who smoke (Asthma= 61%, Diabetes = 35.2% and CHD = 63%).

(GP Practice Profile 2005)

CONCLUSION

This Health Needs Assessment Profile has described the practice population of Faccini House Surgery in its geographical locality and its social structure and activity. It has also given some insight with regard to the views of residents and what it feels like to live in the area (Orr 1992 cited by Tinson 1995). The picture emerging from the collated data is one of an area of relatively high social deprivation. From the locally relevant data a number of comparative needs can be identified, e.g. with regard to some key health determinants such as education, transport, housing and amenities, i.e. the subsystems mentioned above (Tinson 1995). A Participatory Needs Assessment by Merton, Sutton and Wandsworth Health Authority (1998) has described both felt and expressed needs.

This profile has also identified normative needs with regard to the health of the practice population. One of those needs is the high number of chronic disease patients who are also smokers, thus exacerbating their condition. While Tinson (1995) cautions that normative, or professional, assessments can be problematic because they do not always involve the client or community, the identified health need is clearly one to be addressed under the current governments health targets, which describe smoking as the UKs single greatest cause of preventable illness and early death and point out that 70 per cent of smokers say they want to give up (DoH 2004a). Smoking Kills A White Paper on Tobacco (1998) describes smoking as the most identifiable factor contributing to the gap in healthy life expectancy between those most in need and those most advantaged (DoH 1998). Smoking is the single biggest cause of health inequalities and is associated with poverty and social deprivation (DoH 2004a).

Liberating the Talents (DoH 2002) highlights three main core functions for nurses in primary care. As well as being a point of first contact for patients and taking a lead role in chronic disease and minor illness management, they also have a responsibility to deliver health protection and promotion programmes and the various National Service Frameworks. The identified community health need, i.e. smoking among the high-risk chronic disease patients at Faccini House Surgery, relates to the core functions of chronic disease management, health protection and promotion and delivering NSFs (DoH 2001, DoH 2003) and will be addressed by a health promotion intervention in the second part of this paper.

(2192 words excluding tables)

REFERENCES

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PUBLIC HEALTH

PART TWO: HEALTH PROMOTION PROPOSAL

CONTENTS

Page

1.Introduction

1.Context and Theoretical Framework

2. Health Promotion Model Tannahill (1985)

3.Intervention: Planning and Evaluation Framework

(Ewles & Simnett 2003)

4.The intervention

4.Needs and Priorities

4.Aims and Objectives

7. Best Way To Achieve Aims

8. Objectives and Methods

9.Ethical issues

9. Resources

10. Roles and Responsibilities

11. Evaluation Strategy

12.Action Plan

13. Conclusion

15. References

Appendix 1

TABLE 6: Action Plan (Intervention)

Patient invitation letter

Letter to PCT, requesting funding

Proposed budget

Poster

Patient feedback / Evaluation questionnaire

Appendix 2

Determinants of health

Jarman scores - Sutton

Statistics St Helier Sutton and St Helier Merton

Indices of Deprivation 2000 Sutton and Merton

PUBLIC HEALTH

Theresa Lowry-Lehnen

General Practice Nurse

PART TWO: HEALTH PROMOTION PROPOSAL

INTRODUCTION

The Health Needs Assessment Profile in Part One has identified smoking among the high risk groups (i.e. patients with the chronic illnesses, asthma, coronary heart disease and diabetes) within the GP practice population of Faccini House Surgery as a major community health need requiring intervention. Part Two of this paper will devise and critically appraise a clinic-based smoking cessation intervention, targeting chronic disease patients within this GP practice population. It will use the health promotion model suggested by Tannahill (1985) and the planning and evaluation framework devised by Ewles and Simnett (2003). The devised smoking cessation action plan (Table 6, Appendix 1) also incorporates the stages of change model developed by Prochaska and DiClemente (1984 cited by Naidoo & Wills 2000).

CONTEXT AND THEORETICAL FRAMEWORK

Health Promotion Definition

Health Promotion can mean a number of quite different activities, and practitioners must be aware of the available options (Naidoo & Wills 2000). The World Health Organisation defines health promotion as the process of enabling people to increase control over, and to improve, their health (WHO 1984). The current government speaks of delivering sustained improvement to the health of the people by responding to peoples concerns about their health with practical support on their own terms and by providing the context and environment needed to make real progress (DoH 2004a). Naidoo and Wills (2000) point out that the phrase making the healthier choice the easier choice has come to encapsulate the meaning of health promotion. However, Tannahill (1985) claims that the term health promotion has acquired so many meanings as to become meaningless. A more detailed look at an appropriate health promotion model will help to provide a focus and a rationale for the proposed intervention.

Health Promotion Model Tannahill (1985)

Tannahill (1985: 167) suggests reserving health promotion to define clearly a realm of health-enhancing activities. He proposes a model in which health promotion is seen as comprising health education, prevention and protection as three overlapping spheres of activity. Education is seen as a communication activity aimed at enhancing well-being and preventing or reducing ill health in individuals and groups. Preventive action can take the form of prevention of an illness or of avoidable complications of an already established disease. Health protection is defined as legal or fiscal controls, other regulations or policies, or voluntary codes of practice (Tannahill 1985: 168). While in an intervention such as the one proposed here not all parts of Tannahills model may have equal weight, it allows the practitioner to be aware of the possible different activities and available options (Naidoo & Wills 2000). It also enhances an awareness of current policies and national service frameworks (DoH 2001, DoH 2003) and how the proposed intervention fits into government policies and targets regarding smoking as the single greatest cause of preventable illness and early death (DoH 2004a).

Tannahill (1985) stresses that empowerment of individuals and groups within the community is an important objective for health promotion. He warns against a top down approach and advocates a participatory process.

It should be pointed out that no health promotion model can be seen in isolation. There is always a certain overlap with other models, such as Caplan and Holland (1990 cited by Naidoo & Wills 2000) and Beattie (1991 cited by Naidoo & Wills 2000). Similarly, the various possible approaches to health promotion, such as medical, behaviour change, educational, empowerment and social change (Naidoo & Wills 2000), are not mutually exclusive but should complement each other.

Intervention Planning and Evaluation Framework

For the purpose of the proposed intervention the planning and evaluation framework suggested by Ewles and Simnett (2003) will be used. It sets out a seven-stage cycle. I have adapted the planning process to include ethical considerations, as shown in Table 1.

Table 1: Planning/Evaluation Cycle (adapted from Ewles & Simnett 2003)

Identify needs and priorities

Set aims and objectives

Decide the best way of achieving aims

Consider ethical issues

Identify resources

Plan evaluation methods

Set an action plan

Implement plan, including evaluation

THE INTERVENTION

Needs and priorities

The Health Needs Assessment Profile in Part One has identified smoking cessation as a health need to be addressed. In particular, the profile has identified a high proportion of smokers among the chronic illness patients at Faccini House Surgery. Smoking exacerbates such illnesses as diabetes, respiratory and coronary heart disease (DoH 2004a). The priority for this intervention will therefore be smoking cessation targeted at the chronic disease patients within the Faccini House Surgery practice population.

While it may be pointed out that a cessation intervention should be aimed at all smokers, not just those in high-risk groups, the health belief model (Becker & Maiman 1975 cited by King 1984) may be used to support a more targeted approach: As King (1984) states, most people do not tend to think in terms of abstract statistics but rather they think of concrete examples. It is hoped that a cessation programme aimed at the identified high-risk groups may allow a more targeted, and therefore, it is hoped, more successful approach.

Aims and Objectives

According to Ewles and Simnett (2003) aims are broad statements of the outcome one hopes to achieve while objectives are much more specific, making the setting of them a critical stage in the planning process.

The overall aim of this intervention is to address the identified health need, i.e. to reduce the incidence of smoking among chronic disease patients in line with general government and local PCT targets (DoH 1998, 2004a, 2004b, Sutton and Merton PCT 2003a, 2003b, 2003c). With regard to Tannahills (1985) model, this overall aim should be approached in a comprehensive way. The aspect of health protection can be seen in the context of current government policies and targets with regard to smoking cessation (DoH 2004a). Within this context, this proposed intervention devises an educational approach in the form of a communication activity aimed at enhancing the well-being and preventing or reducing the ill health in individuals and groups. The preventive aspect can be seen in the attempt to avoid complications of an already established disease.

It is possible to identify aspects of a number of health promotion approaches (Naidoo & Wills 2002). There is a medical component in that those at special risk have been identified by the practitioner. Individuals may be encouraged to take responsibility for their own health and choose a healthier lifestyle in an approach aimed at behaviour change. There is also the educational element trying to increase knowledge and skills about healthier lifestyles. The overall aim may be achieved by working with clients within the community, thus strengthening their empowerment (Naidoo & Wills 2002).

Objectives must be set in order to enable the practitioner to work towards the overall aim. Ewles and Simnett (2003) stress that objectives are the desired outcome of an intervention and that, while challenging, they should be attainable, relevant and as measurable as possible. On the basis of Tannahills (1985) model, the objectives should cover education, prevention and protection, and Table 2 lists the objectives for this proposed intervention.

TABLE 2: A clinic-based smoking cessation intervention targeting chronic disease patients within a GP practice population

Overall Aim

To reduce the incidence of smoking in chronic disease patients in line with national and local government targets

Objectives

Ensure that every targeted patient on the GP register receives information about the clinic based smoking cessation programme

Educate and empower clients to give up smoking

Impart clear messages about the risks associated with smoking and chronic illnesses

Encourage personal responsibility

Equip patients with skills/knowledge and appropriate nicotine replacement therapy (NRT)

Promote self-esteem in a population already disadvantaged in health terms

Promote inclusion with a community outreach service for those unable to attend clinics

Establish self-help group networks within the chronic disease population

Promote participation and working in partnership

Work within current PCT/Government guidelines on smoking cessation

Best Way to Achieve Aims

In choosing methods for an intervention, one must consider whether they are appropriate and effective, acceptable to clients and others involved and financially viable (Ewles & Simnett 2003).

Working with individuals and small groups has been identified as effective for changing attitudes, feelings and behaviour (Ewles & Simnett 2003).

The objectives identified in the previous section can be listed under such headings as health awareness, improvement of knowledge, empowerment, changing attitudes and behaviour, and societal change, which also correspond to the three spheres of activity identified in Tannahills (1985) model. Adapting the aims and methods identified by Ewles and Simnett (2003), the chosen methods for the objectives in this intervention are group work, group teaching and talks with the opportunity of one-to-one counselling and the appropriate use of NRT, audio visual and written materials. Table 3 groups the objectives under overall goals as well as activities corresponding to Tannahills (1985) model and shows the chosen methods.

TABLE 3: Objectives and Methods (Adapted from Ewles & Simnett 2003 and Tannahill 1985)

GOALS / ACTIVITY

Health Awareness/ Promotion

Education

Knowledge

Empowerment

Changing attitudes and behaviour

Health protection and illness prevention

Reducing inequalities

Participation and partnership working

Societal change/protection

METHODS

Specialist nurses: Talks, education, specialist knowledge

Expert patients: Motivate, support, encourage, role models

Counselling: Change behaviour/attitudes, support, motivate

Outreach nurse: Visit patients unable to attend in the community

Group-work : Patient networking and forming self help groups

Literature: Education, information

Nicotine replacement therapy

OBJECTIVES

Ensure every targeted patient receives information about local smoking cessation programme, impart clear messages about the risks associated with smoking and chronic conditions

Equip and empower patients with skills/knowledge and appropriate nicotine replacement therapy (NRT)

Promote inclusion with a community outreach service for those unable to attend clinics

Educate and empower clients to give up smoking

Encourage personal responsibility

Promote self-esteem

Establish self-help group networks within the chronic disease population

Work within current PCT/Government guidelines on smoking cessation

Ethical Issues

Having set aims and objectives and having decided on the best way of achieving them, it is appropriate at this point to adapt Ewles and Simnetts (2003) planning and evaluation framework by including a consideration of ethical issues. As Jenkins and Emmett (1997) point out, nurses may assume that their perceptions and assessments of a patients health is accurate and corresponds with those of the patient, but there is a danger of manipulating a patient under the guise of health promotion. Not only is it important to establish what health promotion itself is but also what impact nurses own perceptions may have on the implementation of a health intervention (Gott & OBrien 1990). If the concept of empowerment is to be taken seriously, then the patients autonomy must be respected. Group work and group teaching are appropriate methods to allow patients a say in matters which concern them. Those methods also allow the practitioner to take into account the fact that health education cannot be effective without consideration of patients beliefs and attitudes. The health belief model can help to illustrate how a patients beliefs can influence his health-related behaviour (King 1984). In the context of this intervention it means that it must be taken into account how patients may perceive risks and benefits.

Resources

As has already been demonstrated, the proposed intervention fits in with the priorities and targets set by current government policy (DoH 2004a). In terms of material resources, use will be made of nicotine replacement therapy, written material /literature, audio and visual aids and display materials. It is also important to identify existing local self-help groups for the targeted chronic illnesses as well as voluntary organisations such as the British Heart Foundation, Diabetes UK and Asthma UK. The people involved in the intervention (clients and staff) and their commitment, time, skills, knowledge and expertise are the most important resources. Table 4 proposes roles and responsibilities.

TABLE 4: Roles and Responsibilities

Practice Nurses Co-ordinate the cessation programme

Point of contact/support

Overall responsibility Budgets/ Timetable

Evaluate programmeSpecialist Nurses

Respiratory nurse specialist Education

CHD nurse specialist Specialist information

Diabetes nurse specialist Empowerment

GP Prescriptions for NRT Point of contact and support

Expert patients

(CHD, Asthma, Diabetes)Empowerment

Motivation/encouragementRole models

Smoking cessation counsellorNRT adviceOne-to-one and group counselling

Education /Support/ Encouragement

Outreach nurse Community outreach visits

Support /Education/ Counselling

Patients Participation

Share experiences

Provide ongoing support

Form own support networks

Part of decision and evaluation process

Practice managerHousekeeping

Health and safety

Administrative staff Letters/posters/information

Phone calls

Point of contact

Evaluation Strategy

In setting out an evaluation strategy, it is worthwhile assessing both the outcome and the process of the health intervention (Ewles & Simnett 2003). While it may be difficult to measure the outcome for some of the stated objectives, such as encouraging personal responsibility and promoting self-esteem, there are ways in which the overall objective can be measured to some degree. Given the nature of the proposed intervention, two methods of measuring the outcome are most appropriate. Firstly, feedback will be sought from the participants, patients as well as practitioners, both in a more informal way such as a group feedback session and through a more formal questionnaire (Appendix 1). Secondly, and most importantly given the overall aim of the intervention, participating patients will be monitored on a voluntary basis in order to record whether they have given up smoking. It is suggested that the patients will be approached after one month, three months, six months and twelve months to update the record of their progress. For those patients who have given up smoking their health indicators and their own perceptions about their health may be recorded at future appointments.

With regard to evaluating the process, it is suggested that all input in terms of time, money and materials will be recorded, enabling the course facilitator to set the costs against the benefits of the intervention. In addition, the facilitator should keep a diary to allow self-evaluation. Finally, feedback from clients and other practitioners will be sought, both at the end of group sessions and through a suggestion box (Ewles & Simnett 2003).

TABLE 5: Evaluation Strategy

Evaluating the outcome

How many patients give up smoking?

How many patients do not smoke after one, three, six, twelve months?

Record health indicators at future appointments

Record patients perception of his or her own health

Feedback from patients and practitioners: group session and questionnaire

Evaluating the process

Record all input (time, money, materials)

Keep diary for self-evaluation

Feedback from clients and practitioners

Suggestion box

Action plan

The action plan is the final stage in the planning process before the actual implementation of a health intervention. Such a plan draws together the aims, objectives, methods and resources and sets a timeframe, marking either key events or milestones, while also taking account of the evaluation strategy (Ewles & Simnett 2003). The action plan for this health intervention is set out in terms of key events. The intervention will take place over a twelve week period, based on Tanahills 1984 health promotion model (education, prevention and protection) and incorporating the Stages of Change model developed by Prochaska and DiClemente (1984, cited by Naidoo & Wills 2000). This model describes how clients change their behaviour through various stages ranging from pre-contemplation and contemplating change to then making the change (action stage) before a final stage of maintenance, at which the new behaviour is sustained and the client moves into a healthier lifestyle. Table 6 (Appendix 1) sets out the action plan and key events within a set timeframe.

CONCLUSION

This paper has devised and critically appraised a clinic-based smoking cessation intervention, targeting chronic disease patients within a GP practice population. The intervention concerns one of the main needs identified in the Health Needs Assessment Profile undertaken in Part One. Using Tannahills (1985) health promotion model, the planning and evaluation framework suggested by Ewles and Simnett (2003), and the stages of change model developed by Prochaska and DiClemente (1984 cited by Naidoo & Wills 2000), the intervention has been designed to enable people to increase control over, and to improve, their health, thus reflecting the World Health Organisations definitions of health promotion (WHO 1984) and the new public health (WHO 1998). The intervention also takes into account current government policies by responding to peoples concerns about their health with practical support on their own terms and by providing the context and environment needed to make real progress (DoH 2004a). In a wider socio-political context, the current government describes health promotion as one of the key roles of primary care nurses (DoH 2002) and the health service as a whole (DoH 2000, DoH 2004b). In that respect, the Health Needs Assessment Profile and the health promotion intervention can also be seen as a contribution to delivering relevant National Service Frameworks (DoH 2001, DoH 2003).

Above all, the intervention aims not only to improve the health of patients but also to empower them to make the right choices about their own health, providing them with the appropriate knowledge and guidance. This is made possible by taking into account the three overlapping spheres of activity education, prevention and protection - identified by Tannahill (1985) with regard to health promotion. That health promotion should be a comprehensive concept is reflected in the fact that the intervention in this paper includes elements of various approaches, medical, behaviour change, educational and empowerment, as described by Naidoo and Wills (2000).

Using theoretical models and frameworks to explore and address practice-based health needs and interventions allows practitioners to gain a deeper understanding of the concepts of public health. These models and frameworks are useful tools for translating the aims of health promotion, protection and illness prevention into practice. This in turn makes it possible to enhance practice with the ultimate aims of reducing inequalities, improving health and providing better outcomes for individuals and society as a whole.

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